Healthcare Provider Details

I. General information

NPI: 1477362465
Provider Name (Legal Business Name): KETAMINE FOR DEPRESSION SALT LAKE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 5900 S STE 200
MURRAY UT
84107-5432
US

IV. Provider business mailing address

201 E 5900 S STE 200
MURRAY UT
84107-5432
US

V. Phone/Fax

Practice location:
  • Phone: 385-474-6946
  • Fax: 385-355-2782
Mailing address:
  • Phone: 385-474-6946
  • Fax: 385-355-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. NICOLAS SALOMON JR.
Title or Position: DIRECTOR
Credential:
Phone: 385-474-6946